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A Review of Patient Satisfaction: 1. Concepts of

Satisfaction
Article in British dental journal March 1999
DOI: 10.1038/sj.bdj.4800052 Source: PubMed

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patient management

A review of patient satisfaction:

1. Concepts of satisfaction
P. R. H. Newsome,1 and G. H. Wright,2

Against a background of growing consumerism, satisfying

patients has become a key task for all healthcare providers.
This paper reviews current conceptual models of consumer
satisfaction, including the one most dominant in the marketing
literature disconfirmation theory.

Virtually every organisation is nowadays

concerned with satisfying the users of its
products or services be they known as
clients, customers, consumers or patients.
The subject of satisfaction has been studied extensively in the fields of sociology,
psychology, marketing and healthcare
management and while the particular
focus of interest in each individual discipline tends to be quite distinct, common
themes do exist, especially in the
approach to satisfaction found in the
younger discipline of marketing which
draws on conceptual developments presented in the sociology and psychology
literatures. Indeed consumer satisfaction
is at the very core of modern marketing
theory and practice which is based on the
notion that organisations survive and
prosper through meeting the needs of
customers. Ever since the first satisfaction
studies of the 1960s,1 there has been a
proliferation of research on the subject
with an estimated 15,000 academic and
trade articles published on consumer satisfaction during the past two decades
alone.2 This interest is due primarily to
the fact that for a business to be successful
in the long run it must satisfy customers,
while simultaneously satisfying its own
objectives:
The satisfied customer is an indispensable means of creating a sustainable
advantage in the competitive environment of the 1990s.3
Consumer satisfaction with healthcare
has, in recent years, gained widespread
1Senior Lecturer, Faculty of Dentistry, University of
Hong Kong, 34 Hospital Road, Hong Kong; 2Senior

Lecturer, Management Centre, University of

Bradford, Emm Lane, Bradford BD9 4JL, UK
REFEREED PAPER

Received 24.02.98; accepted 08.07.98

British Dental Journal 1999; 186: 161165

recognition as a measure of quality, especially since the publication of the 1983

NHS Management Inquiry and its call for
the collation of user opinion.4 This has
arisen partly because of the desire for
greater involvement of the consumer in
the healthcare process and partly because
of the links demonstrated to exist between
satisfaction and patient compliance in
areas such as appointment keeping,
intentions to comply with recommended
treatment and medication use.5 Since
high quality clinical outcome is dependent on compliance which, in turn, is
dependent on patient satisfaction the latter has come to be seen as a legitimate
health care goal and therefore a prerequisite of quality care:
Put simply, care cannot be high quality
unless the patient is satisfied. 6
This review therefore assumes that satisfying patients is a fundamentally sound
principle and that an understanding of
the nature of satisfaction is desirable if
healthcare providers, not least dental

In brief
Consumer satisfaction, in its widest

sense, is seen as being a complex

process balancing consumer
expectations with perceptions of the
service or product in question.
The zone of tolerance theory explains
how consumers are able to recognise that
service performance may vary along with
the extent to which they are willing to
accept this variation.
Similar mechanisms appear to play a
role in the determination of patient
satisfaction with healthcare, although this
review suggests that the process is far
from being a simplistic comparison
between expectations and perceptions.

BRITISH DENTAL JOURNAL, VOLUME 186, NO. 4, FEBRUARY 27 1999

practitioners, are to deliver quality care

and succeed in todays rapidly changing
business and economic environment.
Part 1 of this paper presents an overview
of the way user satisfaction is presented in
the marketing literature and wider
healthcare literatures. Part 2 then reviews
recent literature dealing specifically with
dental patient satisfaction.
Consumer satisfaction
the marketing perspective

The marketing literature originally saw

consumer satisfaction as being an outcome resulting from the consumption
experience:
The buyers cognitive state of being adequately or inadequately rewarded for the
sacrifices he has undergone.7
More recent definitions, however, see
satisfaction as a complex evaluative
process:
An evaluation rendered that the (consumption) experience was at least as good
as it was supposed to be.8
This latter approach is now much more
widely accepted since, compared to the
outcome-oriented approach, it takes into
account the social-psychological determinants of satisfaction, that is the perceptions, evaluations and comparisons
which precede an evaluation.
Disconfirmation theory

By far the most dominant of the conceptual models of consumer satisfaction

disconfirmation proposes that the
consumer compares his or her perceptions of the product or service against a
pre-purchase comparison level or standard, the most widely researched being
consumer expectations.9 Satisfaction is
then mediated by the size and direction of
disconfirmation the difference
between an individuals pre-purchase
expectations and the performance or
quality of the product or service. As far as
services are concerned this quality assessment comprises consumer perceptions of
a number of service attributes:10
Reliability: ability to perform the
promised service dependably and accurately

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patient management

Responsiveness: willingness to help customers and provide prompt service

Assurance: employees knowledge and
courtesy and their ability to inspire
trust and confidence
Empathy: caring, individualised attention given to customers
Tangibles: appearance of physical facilities, equipment, personnel, and written
materials.
The terms satisfaction and quality
assessment are often used interchangeably
and while they have certain things in common, satisfaction is generally seen to be the
broader concept and one that can be
viewed either at the individual service
encounter (transaction) level or at a more
global level, encompassing all experiences
with an organisation.11 Perceived quality is
just one of a number of antecedent factors
driving satisfaction.11 This can be illustrated by the observation that quality perceptions can occur in the absence of actual
experience with an organisation:12 I know
Dr X provides a high quality service, even
though I have never been treated by him
whereas consumer satisfaction or dissatisfaction can only arise following an actual
experience with the organisation: I cannot
tell you how satisfied I am with Dr X
because I have never been treated by him.
It is also important to stress that it is perceived quality that is important:
The notion of objective performance is
an indefinable state in most cases. All
attribute performance will be judged by a
service user in perceptual terms. Even
with an apparently objective measure,
such as waiting time, it is not so much the
absolute time but the evaluation of it, as
being long/short, or acceptable/unacceptable, which will always be subjective,
dependent on the evaluator. 13
Disconfirmation theory proposes that,
all things being equal, the higher ones
expectations, the less likely that service or
product performance can meet or exceed
them, the result being reduced satisfaction or even dissatisfaction; the higher the
perceived level of performance, the more
likely that expectations will be exceeded,
resulting in increased satisfaction. This
has led some observers to recommend

162

deliberately underpromising the service

to increase the likelihood of meeting or
exceeding customer expectations.14 Zeithaml and Bitner12 argue, however, that
while underpromising makes expectations more realistic, thereby narrowing
the gap between expectations and perceptions, it may also reduce the competitive
appeal of the offer. Research also indicates
that underpromising may have the inadvertent effect of lowering customer perceptions, especially in situations where
consumers have little experience with a
product or service.15 In addition, there is
evidence to suggest that raising expectations prior to use often results in
increased perceptions about performance
even though the product or service may
have performed poorly.16 In this latter
instance expectations are influencing satisfaction independently of perceptions,
an effect which has been explained by the
assimilation-contrast theory. This theory
combines elements of Festingers theory
of cognitive dissonance17 which holds
that when an individual receives two ideas
which are dissonant, he or she attempts to
reduce this mental discomfort by changing or distorting one or both of the ideas
to make them more consonant. Disconfirmation theory suggests that when perceptions of attribute performance differ
only slightly from expectations, there is a
tendency for people to displace their perceptions toward their expectations the
assimilation effect. There comes a point
either side of this range though where
people can no longer effect displacement
and instead they begin to exaggerate the
increasingly large variation between perceptions and expectations the contrast
effect. A number of studies have also
found that the effects of expectations
differ under different conditions, between
consumer groups, across different product categories (high against low consumer-involvement products), and
between products and services.1822
Types of expectation

In an attempt to explain more fully these

differences and contradictions, researchers
are taking a broader view of the term

expectations, realising that consumers

can and do hold several different types of
expectation and that these are characterised by a range of levels, rather than a
single level. As LaTour and Peat have
observed, using expectations only in the
sense of what will happen leads to logical
inconsistencies such as predicting that a
consumer who expects, and subsequently
receives, poor performance will somehow
be satisfied.23
In terms of services, Zeithaml and Bitner12 distinguish between three types of
expectation. The first is desired service,
defined as the level of service the customer hopes to receive, the wished for
level of performance blending what the
customer believes can be and should
be. Customers hope to achieve their service desires but recognise that this is not
always possible and for this reason they
hold a second, lower level expectation,
adequate service, representing the minimum tolerable expectation or bottom
level of acceptable performance. Finally,
predicted service is the level of service
customers believe they are likely to get
and implies some objective calculation
of the probability of performance.
Zeithaml and Bitner argue that customers recognise that service performance may vary and that the extent to
which they recognise and are willing to
accept this variation is called the zone of
tolerance.12 In theory predicted service
could equate with either adequate or
desired service but is most likely to fall
between the two and hence within the
zone of tolerance. The zone of tolerance
is seen as the range or window in which
customers do not particularly notice
service performance. When performance falls outside the range (either
very high or very low) the customer
expresses satisfaction or dissatisfaction.
Customer tolerance zones are thought
to vary for different service attributes
and the more important the factor, the
narrower the zone of tolerance is likely
to be.24 Figure 1 shows the tolerance
zone concept and portrays the likely difference between the most important
(eg service outcome the result of the

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patient management

service) and the least important factors

(eg service process the way the service
is delivered).
Other influences

In addition to expectations, themes such

as equity and attribution have also been
proposed as determinants of consumer
satisfaction. Social equity theory is particularly relevant to satisfaction with services and asserts that individuals
compare their gains (the balance of what
they put in and what they get out) with
those of other consumers and with those
of the service provider.25 Satisfaction is
thought to exist when an individual perceives that the outcome-to-input rations
are fair. Fisk and Young explored equity
theory in the setting of an airline and
found that inequitable waiting and pricing (ie detrimental to the consumer) led
to consumer dissatisfaction.26 Perhaps
not surprisingly positive inequity (ie
beneficial to the consumer) was seen to
be fair or satisfactory by consumers. The
concept of equity relates to the theory of
social comparison27 which spells out the
way social comparisons influence the
formation and evaluation of opinions
people ascertaining whether their opinions and evaluations are correct by comparing themselves with other people.
Attribution theory, on the other hand,
comes into play when products or services fail to meet consumer expectations
and assumes that people search for
causes of events, such causes being either
buyer-related or seller-related. Buyer and
seller may infer different reasons for failure so leading to conflict which results in
dissatisfaction.28
The marketing approach to conceptualising satisfaction draws heavily on the
work of Fishbein and Ajzen into beliefs
and attitudes.29 Central to this approach is
the notion that satisfaction arises out of an
interplay between cognitive and affective
processes. According to Fishbein and
Ajzen perceptions,29 including beliefs, are
cognitive in nature (referring to the process
of knowing or thinking) and represent the
information an individual has about the
object in question while attitudes, on the

Fig. 1 The zone of tolerance for different service dimensions

other hand, are affective in nature (referring

to the process of emotion) and are characterised by a general evaluation or feeling of
favorableness or unfavourableness toward
the object. As far as satisfaction is concerned, the expectation formation process,
the comparison of performance to expectations or desires, and judgments based on
equity and attribution are mostly conscious,
overt activities and therefore primarily cognitive in nature. The role that affective
responses, not under conscious control, play
in the satisfaction process is less well developed. However, it is now accepted that a
variety of emotional responses, including
such affects as joy, excitement, pride, anger,
sadness and guilt do play a significant,
complimentary, role in determining satisfaction.30 Indeed satisfaction (or dissatisfaction) can be viewed as a positive (or
negative) affective response. Blending
these various theories results in the conceptual model of consumer satisfaction
shown in figure 2.
Patient satisfaction
the healthcare perspective

In a seminal paper on the subject of

patient satisfaction Locker,31 noted that
the preoccupation of most researchers at
that time was with identifying sociodemographic correlates of satisfaction
rather than developing a solid sociopsychological theoretical understanding.
Since then a number of studies have
been conducted to find out more about
how patients evaluate the care they
receive and to develop conceptual models of patient satisfaction. The majority
of these models have been reviewed
extensively by Pascoe,32 with most

BRITISH DENTAL JOURNAL, VOLUME 186, NO. 4, FEBRUARY 27 1999

including the role of expectations as a

central component of the satisfaction
process. Oliver, for example, examined
flu shots and found that positive disconfirmation (ie perceived performance
above that expected) increased consumer satisfaction, while negative disconfirmation (ie perceived performance
below that expected) decreased consumer satisfaction.9 A growing number
of researchers, however, are of the opinion that patient satisfaction and consumer satisfaction are not one and the
same thing, and that the marketingoriented conceptual model does not easily fit, or is simply inappropriate for,
many common medical scenarios. What
follows is a discussion of the reasons
why satisfaction with healthcare might
be different.
Healthcare studies

The most commonly-cited reservation

concerns the role that expectations,
which are central to the consumer
model, play in determining satisfaction
with healthcare. The work of LinderPeltz33,34 on the interaction between
patient expectations and perceptions is
seen to be particularly influential in this
respect. Data concerning patients
healthcare values, expectations and
sense of entitlement to care were collected from 125 first-time patients at a
primary care clinic, immediately before
seeing a physician. Post-visit satisfaction
with a number of dimensions of care
was also recorded. Two findings from
this research suggest that disconfirmation theory might not be an entirely
appropriate model for the healthcare

163

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patient management

Fig. 2 A composite Cognition-Affect model of satisfaction as proposed by Oliver.30

Cognitive antecedents include expectations, performance, disconfirmation, attribution
and equity/inequity. Expectations and performance may exert a direct effect upon
satisfaction or may be mediated indirectly through the process of disconfirmation.
Affect, both positive and negative, is seen as another intermediary between both
performance and attribution. Equity is postulated as a further distinct contributor to
satisfaction, unrelated to affect or other cognitive components

setting. The first is that, in spite of being

the most important antecedent socialpsychological variable, patient expectations could only account for 8% of the
variance in satisfaction and, together
with values and perceptions (of the service received), only 10% of the variation. This suggests that while there is
evidence that patients expectations and
values are involved in evaluations they
do not appear to be related in any simplistic fashion. According to this study
there is little evidence to suggest that satisfaction is largely the result of fulfilled
expectations and values.
Linder-Peltzs second important finding is that expectations have an effect on
satisfaction independent of other variables
(ie irrespective of their fulfilment) leading
the author to conclude that:34
...beliefs about doctor conduct prior to
an encounter play a significant role in
determining subsequent evaluations of the
doctor conduct, irrespective of what (s)he
actually did or was perceived to have done.
It suggests that patients are likely to
express satisfaction no matter what care
the doctor gives, at least in the setting of the
present study. Practically, the independent
effect of expectations on satisfaction with

164

doctor conduct implies that clinic staff

and particularly doctors themselves can
ensure the satisfaction (favourable ratings) of their clients by engendering positive expectations. With regard to health
services research, this finding suggests that
knowledge of patients expectations can
tell a great deal about how they will later
rate the visit.
This is not to say that expressions of
satisfaction have little to do with the
qualities of the service provided or the
care offered and clearly engendering
positive expectations must not be confused with raising false hopes which
deliberately mislead patients, nevertheless the assumption that satisfaction is
entirely the product of an evaluation per
se may not apply in all situations. In this
regard Zeithaml et al.,35 have noted that
while consumers ultimately judge the
quality of services on their perceptions of
the technical outcome provided and how
that outcome was delivered (process
quality), many professional services are
highly complex and a clear outcome is
not always evident. This is certainly true
of many healthcare scenarios where the
technical quality of the service the
actual competence of the provider or

effectiveness of the outcome is not

easy to judge. The patient may never
know for sure whether the service was
performed correctly or even if it was
needed in the first place. For example,
Williams has observed that the greater the
perceived esoteric or technical nature of
treatment the more likely it is that many
service users will not believe in the legitimacy of holding their own expectations,
or of their evaluations.36 In addition, if a
service user is coming into contact with
the system for the first time then expectations, which for many have been formed
through past experience, might be waiting formation. In both cases a patient
might wish for the health professional to
adopt a paternalistic role in the relationship (doctor knows best) while they
themselves remain a passive partner.
Donabedian sees quality of healthcare
as a trilogy comprising structure,
process and outcome.37 Zeithaml et
al.,35 however, argue that service users
who cannot judge the technical quality
of the outcome effectively will base their
quality judgements on structure and
process dimensions such as physical settings, the ability to solve problems, to
empathise, time-keeping, courtesy and
so on. Shaw concurs with this view in a
review of satisfaction studies of the
social services:38
Client evaluations are relative to context, to knowledge of services, to expectations, to help received from other services, to
perceptions of the pleasantness of the social
worker. Unless such factors are taken into
account, we can never be sure whether the
high rate of client satisfaction is related
more to factors like knowledge or limited
expectations, than the actual helpfulness of
the social service contact.
The zone of tolerance concept seems to
be particularly applicable to the healthcare setting and could explain the findings of a study looking at the effect of
good and bad surprises on satisfaction
levels.39 The study was particularly concerned with the effect of social norms
which the user might only become conscious of when transgressed; good surprises being defined as care going well

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beyond what was expected and bad surprises equivalent to the transgression of
typical values. The results indicate that
the majority of those relating a good surprise (above the level of desired service)
or no surprise (within the zone of tolerance) expressed satisfaction while those
who had experienced a bad surprise
(below the level of adequate service)
were more likely to have expressed dissatisfaction. The satisfaction processes at
play are likely to differ in the same individual depending on the severity of the
condition he or she presents with.
Patients will probably use different criteria to judge the management of a lifethreatening emergency as compared to a
routine health check and evaluation may
differ depending upon whether it is the
patient or the health professional who
identifies the problem in the first place.
Clearly, healthcare is not homogeneous;
it is a distinctive, complex mixture of
emotion, the tangible and the intangible,
and its consumption cannot be viewed in
entirely the same light as that for a consumer product such as a television or a
washing machine.

1
2
3

4
5

6
7
8

9
10

11

Conclusion

At first sight the notion of satisfaction

may seem unproblematic but as yet
there is still no common and unifying
definition of the concept. Disconfirmation theory is the most widely accepted
in the marketing literature although it
does not fully explain the whole evaluation process and it is likely that future
research will concentrate on the roles
played by such phenomena as attribution and equity.
This appears to be especially so in the
case of satisfaction with healthcare
where elements of the consumer model
do apply although the roles played by
patient expectations, perceptions and
disconfirmation are not yet fully understood. Much seems to depend on the
way patients perceive themselves in
relation to the healthcare system and it
is possible that some patients might
simply remain passive and not evaluate
the service provided.

12
13

14
15
16
17
18
19
20

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